August/September 2007 Volume 1, Number 1
From Larry Noonan — Page 2
Playground upgrade — Page 2
Auto detailing shop — Page 3
— Page 7
New email server — Page 8
Legislative Update — Page 9
Shrink wRap with Dr. Ira Lourie — Page 12
Worth Reading — Page 13
Quality Assurance — Page 15
News Digest — Page 16
Administrative Notes — Page 16
Photo by Sheila Horsley
Nurse Happy Richards and Leonard Lamping at the remodeled Porphyry Home in Butte.
Community Living Initiative
Residents trade institution for neighborhood
The men and women from the Total Care Unit at the Montana Developmental Center in Boulder are enjoying life in their own homes this summer after spending years – decades in some cases – in dormitories with block walls and concrete floors. The last resident from the unit moved into her new home on Sampson Street in Butte on June 26. Through an initiative led by AWARE,
she and 13 other people are doing everyday things other Montanans who haven’t been shut away in institutions do. They sleep in their own bedrooms in light-filled, tastefully decorated homes. They eat their meals at their dining room table. They go outside in their yards and neighborhoods, experiencing the weather, the sun, and the change of season. They swim once a week at the YMCA. See Total Care on page 4
Adult Case Management program expands The State of Montana’s Department of Public Health and Human Services (DPHHS) recently awarded AWARE twoyear contracts to provide Targeted Case Management in Missoula, Billings, and Columbus.
AWARE Targeted Case Management now serves over 300 adults affected by developmental disabilities in 17 Eastern Montana counties. With the addition of the contracts, that number will reach more than 500 individuals. See Expansion on page 8
Hello, Staff and Friends, I wanted to take a moment to touch base with all of you, something that becomes harder as time goes on and we continue to expand our service offerings and their reaches across the state. Ideally, this newsletter can be a voice for our communities, staff, and friends. We have so much going on administratively, creatively, and technically that there will never be a shortage of material to discuss. In this issue, you’ll be given insight into the journey of 14 adults from the “AB Unit” of the Montana Developmental Center to our new, state-of-the-art Porphyry home in Butte and the Bubash home in Anaconda. It’s a remarkable story about the lives of these individuals finally being centered in community. You’ll also read stories documenting an auto detailing business staffed by A.W.A.R.E. Work Services employees in Billings, the recent awarding of two major Targeted Case Management contracts to A.W.A.R.E., the beautification of the Early Head Start playground in Butte, a legislative digest that focuses on all legislation related to the work we do, a message from our medical director, Dr. Ira Lourie, and much more. The fact that we are generating so much news is testament to the work and support all of you provide, day in and day out, and it shows no signs of slowing.
So, enjoy these stories that say so much about who we are, on every level, and I’m looking forward to more! With best regards,
Butte contractor donates time and energy into refurbishing Early Head Start playground
The neighborhood where you’ll find AWARE’s Early Head Start and main office was once home to Butte’s hardest-living, rough and tumble residents. That neighborhood was a well-known slum coined “The Cabbage Patch.” The area primarily consisted of oneroom shacks, torn down in the early 1940s to make room for a public housing project, save for four of the original shacks, orange and rust-colored shanties directly behind the AWARE offices on Mercury Street. How things can change. AWARE’s purchase of the property in the heart of the former slum led the way in the revitalization of the area…a slow process, but a worthy one. See Contractor, next page
Tom Reopelle of Reo Building Systems donated time and effort to improve the playground at AWARE’s Early Head Start in Butte.
Contractor... Soon after, a senior citizen’s center was built down the road on Mercury. Most recently, REO Building Systems began work on a condominium project directly north of AWARE’s offices, and, in return for a small donation of land, Tom Reopelle, owner of the firm, agreed to donate over $8,000 worth of time and materials needed to upgrade the playground used by Early Head Start. The upgrade includes: New sod, a new slide built into the small hill of the playground, a permanent shaded area, miscellaneous lawn furniture and play equipment. “This goes beyond new toys,” states Tom Richards, director of AWARE’s Early Head Start program. “Outdoor lesson plans refine motor skills, promote social adjustment, and give kids, and their parents, for that matter, the sense that we are trying to provide them with the very best.” The construction has already begun at the playground in varying increments, which Mr. Reopelle is folding in between his already hectic summer construction schedule. “It’s easy for us to lose sight of the simple things that make a child happy, and, frankly, doing this kind of work for the benefit of kids is the furthest thing from work for my staff and I,” says Reopelle “…we’re thrilled to do it.” By Tim Pray
Lawrence P. Noonan, CEO Geri F. Wyant, CFO Jeffrey Folsom, COO Mike Schulte, CHO Board of Directors John O’Donnell, President, Allan Smith, Vice President Teresa Marshall Cheryl Zobenica Keith Colbo John Haffey Written and Edited by Jim Tracy and Timothy Pray
Tim Knutson polishes the inside door of a pickup truck at AWARE’s auto-detailing shop in Billings.
Attention to detail
Billings auto cleaning crew takes a shine to their work
The crew at AWARE Auto Detailing in Billings can finish two vehicles in a day, making them shine from bumper to bumper. On a recent Thursday morning, Nick Spelts, Vyeron Foote, Tim Knutson, Colleen Coe and Deborah Battleson, under the supervision of Joe Lucero, went to work on a dark green Dodge pickup truck. When they finished, the truck gleamed inside and out. It had that new car smell, too. The auto detailing shop operates out of a high-ceilinged warehouse at 1050 S. 25th St. West. The shop is attached to AWARE’s administrative offices and Day/Work Services. AWARE details vehicles for the Used Car Factory, a car dealership on State Avenue in Billings. “They’ve been very pleased with the job we do,” said Lucero, who has worked for AWARE for four years. See Detail on page 11
Total Care... They take evening walks and Sunday drives. Giving the folks from the Total Care unit a chance at life in the community has taken the collaborative efforts of AWARE working closely with state officials and staff at Boulder. AWARE won a contract with the state in December 2005 to transition 14 residents of the unit to community living. “Our Community Living Initiative has opened up community life to these Montanans who have among the most severe levels of disability in the state,” said Larry Noonan, AWARE CEO. “The Initiative has again showcased for Montana DPHHS all the various expertise AWARE has in successfully implementing a complex de-institutionalization project of this kind. We hope that the department believes the AWARE Initiative is one of the best decisions the department has ever made.”
‘Great leadership’ Noonan credited Jeff Sturm, Developmental Disabilities Program director at DPHHS, with helping push the initiative. “He showed great leadership in making the Developmental Disabilities program a state leader in Olmstead implementation,” Noonan said. Moving the residents of the unit to homes in the community wasn’t just a gesture of good will. It was required by law, specifically an order in the 1999 Olmstead decision handed down by the U.S. Supreme Court. In what has become known as the “integration mandate,” the high court affirmed the right of individuals affected by disabilities to live in communities. Under Title II of the federal Americans with Disabilities Act, Justice Ruth Bader Ginsburg delivered the majority opinion of the court, requiring states to place people with disabilities in community settings
‘Thanks for being there…’ We at the Montana Developmental Center are a bit sad to see the end of an era at MDC. The halls of 16AB are very empty and quiet and the 16AB staff have moved into their new assignments. We miss the faces and voices of the people who have left us, but we are excited about the changes that are happening in their lives. While it is always hard to say goodbye to friends who we have given a piece of our hearts and who have been a big part of our lives, we are happy for them that they have this new opportunity in their lives. MDC and AWARE have worked for the past two years to make sure that the movement of the last few people living at MDC with significant medical and physical Kathleen Zeeck needs was the best possible move. This process has been very challenging for everyone, but the staff from both agencies have been dedicated throughout the process to making sure that the people we serve get the best we can give them. AWARE staff and MDC staff have spent many productive hours working for a smooth transition for the people we care for. MDC would like to thank the staff of AWARE for the positive collaboration and cooperation we have shared to get things happening. We wish all of the people served at AWARE and their staff the very best. It has been a long process, but a good one. Thanks for being there with us. Kathleen Zeeck, Facilities Director Montana Developmental Center, Boulder rather than in institutions. The mandate requires public agencies, such as the Montana Department of Public Health & Human Services, to provide services “in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” Related to the Olmstead decision in Montana, the Travis D. class action lawsuit, filed by the Montana Advocacy Program (MAP) in 1996 on behalf of individuals with
developmental disabilities, sought to protect the civil rights of individuals with disabilities and their right to appropriate community services. MAP’s Travis D. settlement agreement with the State of Montana spells out what’s expected in developing community services as an alternative to institutional care at the Montana Developmental Center. AWARE’s Community Living Initiative is in keeping with this settlement agreement.
“I think opening purchased and remodeled in up community life for Butte, making room for the residents. Two residents were persons with disabilities able to move into the Bubash still in institutions is what home in Anaconda. AWARE does best,” Noonan said. “It’s really “We were looking for homes for sale we could at the heart and soul of our revamp to make them mission, so it’s kind of accessible but realized exciting.” our own homes offered “We hope to educate policy makers on how this the ideal fully accessible environment,” O’Neil said. has worked,” he added. “All the homes were “People still argue that the freshened up substantially institution is where people and individualized. We with severe disabilities can Formers residents of the Montana Developmental Center enjoy life on made specific modifications be best served; we hope appropriate to the needs of the success of the initiative tree-lined Porphyry Street in Butte. the individuals who are living and other AWARE deprograms to meet those unique needs, there.” institutional efforts will help change and recruiting and training staff to The Porphyry home underwent this mind-set. The initiative is really work with the new residents. the most extensive changes to in keeping with what AWARE has Schulte and Oaas, both with accommodate people who require done over and over again – serving decades of experience developing intensive, 24-hour-a-day care people others said couldn’t live in the quality services for persons affected community. by developmental disabilities, focused Mobility impairments “It’s about sitting down, “All of the residents at Porphyry understanding what people’s needs are that expertise on meeting the needs of the residents. are very medically fragile,” O’Neil and designing a program and housing Michael O’Neil, AWARE said. “All have significant mobility that meet their needs. We would Program Officer and director of the impairments.” hope this would become a model in AWARE-led Montana Home Choice AWARE installed special Montana and across the country. Our Coalition, directed efforts to find equipment at a cost of about $70,000, new residents received good care housing to best meet residents’ needs. including a state-of-the-art Horcher at Boulder, but there is an essential The Coalition, which is dedicated lift system that allows staff to move difference between institutional living to creating better community housing residents around the house in a sling and having the opportunity to live in choices for people with disabilities, on a ceiling-mounted track. the community.” including seniors, has made it a The system protects the safety of The right services priority to develop housing that allows residents and staff alike by eliminating people in institutions to live in the the need for manual lifts. AWARE personnel worked community. AWARE also installed a special closely with staff at the Montana After an intense search, looking whirlpool lift tub imported from Developmental Center, looking at at both purchasing homes and new Germany that makes it easy and safe and understanding the needs of each development options, AWARE for staff to help residents with their person. Meeting those needs in the daily baths. community with the right services and settled on three fully accessible homes it already owned. With wide housing instead of in an institution Remodeling at the residences and doorways and hallways, and accessible the new replacement youth homes was AWARE’s job No. 1. bathrooms, the homes — on Porphyry, was done by Dale Harris Construction AWARE staff, notably Mike and Sampson streets and Mystic Lane of Anaconda. The projects allowed Schulte, AWARE Chief Habilitation — seemed a perfect fit for the needs of AWARE to showcase its new, inOfficer for Development Disabilities the unit residents. services, and Behavioral Services house construction capacity under These properties had been homes Specialist Knute Oaas, laid the Steve Francisco, AWARE Facilities for three adolescent youth programs. Manager. groundwork last year for the move The teenagers did not fully use or “From a time and cost perspective, from Boulder, meeting with residents need the accessibility features in the AWARE taking on direct construction and their families, clearly defining homes, so the adolescent programs the needs of each person in terms of Continued on page 6 both housing and services, developing relocated to three new homes AWARE
Total Care... activities gives us a unique advantage in cost effectively adapting environments, both in housing and service facilities, to the needs of the persons we serve,” Francisco emphasized. On the staff side, Micki Mattson, a registered nurse with extensive experience in nursing homes, was hired as nursing coordinator for the homes. Her nursing staff includes five licensed practical Andy Doggett, Joe Kroll, and Leonard Lamping enjoy a Montana afternoon at their home in Butte. nurses, who help provide seven-day-a-week nursing Schulte. “It’s about individualizing our $1.6 million in financing and dedicated services, including weekends and services rather than using a cookieorganizational resources. evenings. cutter approach.” Geri Wyant, AWARE Chief At the same time, there’s a Some of the people who moved Financial Officer, acknowledged that familiar face overseeing the residents’ from Boulder had lived in the the Initiative stretched AWARE’s medical care. institution for as long as 25 years. A finances. Dr. Jean Justad of Helena, a few had lived nearly their entire lives “Opening up community life for specialist in internal medicine who had there. people with disabilities is treated the residents while they were “This group as a AWARE’s primary mission, eople living at the Developmental Center, whole is considered to so putting our organizational visits them twice a month at their new have total care needs,” said the financial resources to work homes under a special arrangement O’Neil said.” Some behalf of the residents of move couldn’t on with AWARE. cannot speak. Others the unit is just one way we be done, but “Dr. Justad knows them cannot walk. This fulfill this mission,” Wyant personally, and she knows their Initiative shows that AWARE did it said. medical needs better than anyone,” people with even the For Noonan the again. — Larry move has been a personal Oaas said. severest disabilities can and should live in Noonan and professional victory Swimming at the Y the community” — a chance to prove the AWARE has integrated the O’Neil hopes the naysayers wrong. homes with its other programs, Initiative will be a model for Montana “People said the move couldn’t including work services and supported and other states as they try to comply be done, but AWARE did it again,” employment. Residents can also with the Olmstead decision. Noonan said. take advantage of transportation and AWARE received $450,000 in Now the people who once were medical care, including physical and funding from the Montana DPHHS shut away at Boulder live in beautiful occupational therapy. Among their Developmental Disabilities program homes along tree-lined streets in weekly activities is a trip to the Butte to facilitate the residents’ transition, friendly neighborhoods in Butte and Community YMCA for a swim, and developing the housing and services Anaconda, enjoying the extraordinary other community outings. and hiring and training 48 new staff in the ordinary of everyday “We work hard to determine each to meet residents’ needs seven days a community life. individual’s unique and changing week, 24 hours a day. By Jim Tracy needs and wants to provide the best AWARE leveraged state funding tailored services for each person,” said with the commitment of an additional
Initiative boosts local economy
AWARE’s latest effort to support persons with disabilities to transition to community living creates jobs and a multi-million dollar annual local economic impact. According to AWARE’s analysis, the AB Community Living Initiative has created 42 new “living wage” jobs with full benefits, resulting in more than $1.2 million in annual sustainable long-term direct economic activity in Silver Bow County, including direct wages and local purchasing. Immediate short-term economic activity totaled $1,360,000, including real estate purchases, construction, program development wages and purchases for furnishings, appliances and medical equipment. The total project budget for the start-up of the initiative was $2.1 million. That included $560,000 of AWARE financing, $590,396 of AWARE “organization resources” and commitment of assets, and $450,237 in grant funding through the Montana Department of Public Health & Human Services Developmental Disabilities Program. AB Community Living Initiative Economic Impacts (using conservative economic multipliers) 60 total health care and other jobs created (utilizing 1.4 Medicaid employment multiplier effect). Among the workers AWARE hired were RN’s, LPN’s, habilitation technicians and night watch technicians. $1.6 million in annual sustainable county total economic impact (using the 1.32 Medicaid combined economic impact ripple effect on income multiplier) $20.3 million estimated total initial 10-year county total economic impact. The new programs are based at three homes AWARE owns and operates in Butte. The properties on Mystic Lane, Porphyry Street and Sampson Street underwent significant renovations and specific modifications to create ideal homes for the 12 residents to be served. The first residents of the Porphyry home moved in on Oct. 31, 2006. All residents of the Porphyry and Mystic homes were settled in the community by mid-December. The final residents moved into the Sampson residence in June 2007. Each new employee in the program received specialized training with an estimated average costs of $1,200 per employee. Training included CPR, first aid, behavioral management techniques, consumer rights and specific trainings geared to the needs of the persons with disabilities served.
Learn about fair housing at a special training session in Helena, Tuesday and Wednesday, Aug. 28-29. This two-day workshop presented by HUD’s Fair Housing investigators will cover compliance with Section 504 and Section 3. Find out what federally funded housing providers need to do to ensure they are in compliance. The sessions run from 9:30 a.m. to 4:30 p.m. both days at the Park Plaza Hotel at 32 North Last Chance Gulch. Lodging at government rates will be available until Aug. 14. Call 406 4432200. For more information on the workshop, contact Faith Ballenger or Robin Brown: faith.a.ballenger@hud. gov or firstname.lastname@example.org; or call the HUD Helena Field Office at training 406-449-5050. For additional information, visit www.hud.gov, and select “Montana” from the drop down “select-a-state” menu. The Children and Families Interim Committee has set Sept. 24, for its next meeting in Room 137, Capitol Building. The joint bipartisan committee of the Legislature meets between legislative sessions to monitor the Department of Public Health & Human Services; conduct interim studies; and generally review issues related to health and human services. The committee is made up of an equal number of members from each political party and each legislative chamber. House members are Edith Clark, R-Sweet Grass; Ernie Dutton, R-Billings; and Teresa Henry and Diane Sands, both Missoula Democrats. Senate members are Carol Juneau, D-Browning; Rick Laible, R-Darby; Terry Murphy, R-Cardwell; and Dan Weinberg, D-Whitefish. In June, committee members elected Rep. Clark as presiding officer for the interim and Weinberg as vicepresiding officer. Visit http://www.leg.mt.gov/css/ committees/interim/2007%5F2008/ for more information.
AWARE converts to in-house e-mail system Software enhances security
The number of employees with an AWARE email address – “aware-inc. org” – has more than doubled since April with the addition of an in-house server. Installed in April, the Microsoft Exchange Server allows the information technology department – aka Nick Rub in Billings and Wendall Smith in Anaconda – to manage AWARE email. Now if something goes wrong, “We can fix it and keep down-time to a minimum,” Smith said. “We don’t have to make phone calls and rely on someone to fix it. Another advantage is that there is no monthly charge for extra emails.” The new server also gives the IT department tighter control over what comes into the system. Like info techs everywhere, Smith and Rub must contend with e-mail security threats continually evolving spam and viruses, the vulnerability of e-mail to interception and tampering, and “phishing” – the sending of an e-mail to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. Smith said the new server allows AWARE to protect itself against those threats. At the same time, it gives employees more efficient access to e-mail, calendars, attachments and contacts than before no matter where they are or what type of device they are using. Through Exchange, AWARE has licenses for 250 “aware-inc.org” emails. So far, 144 employees have that address. Only 75 AWARE emails were available with One West, the former system provider. Smith noted that the Exchange Server supports Microsoft Outlook – from Outlook on the desktop to Outlook Web Access over the Internet. Employees looking for help
setting up Outlook can visit the AWARE corporate web site: Go to the “AWARE, Inc., Login Main Page,” log into the system, click on “PDF Manuals” and then scroll down to “Information Technology” and click on it. That will open a page that allows access to all current AWARE emails and instructions for setting
up AWARE email using Internet Explorer and for setting up AWARE email using Microsoft Outlook 2003. If you have questions, you can call Smith in Anaconda at 563-8117, ext. 53, or Rub in Billings at 6560928, ext. 15. Or send them an email: email@example.com or nrub@ aware-inc.org.
Expansion... Several other providers in each of the Billings, Columbus, and Missoula areas submitted proposals to the DPHHS in hopes of being awarded the contracts. Tim Plaska, coordinator of the review committee that rated the proposals, states that the contracts were given to AWARE based on the fact that “AWARE, Inc. is a diverse organization with a history of success, as well as a clear vision of the future.” During the course of this legislative session, House Bill 2 mandated that the caseloads of Montana Case Managers be reduced from 47-50 clients to 35 clients, a move that has allowed us to bring Adult Targeted Case Management services into areas that we had not been providing for in years past. The bill had the strong support of Jeff Sturm, the director of Montana’s Developmental Disabilities Program, who says that “people will be getting better service because there will be smaller caseloads.” “We’ve always been confident in our ability to provide services that help individuals affected by developmental disabilities…services which allow them to live their lives in a way that affords them the highest quality of life possible,” states Jaci Noonan, AWARE’s Director of Adult Case Management. “It’s also important to note, though, that our services are only as good as the people delivering them, and the trust the state has shown in our ability to deliver services properly is in direct proportion to the trust we put in our staff to deliver them…this is a testament to the quality of work being done every day by our staff in the field.” Many things make AWARE services what they are, and earn them the respect that they have throughout the state. In order for us to be as highly accredited as we are, various systems of checks and balances are put in place, either by an outside agency such as the state, or the Commission on Accreditation of Rehabilitation Facilities (CARF). However, there is much we do by way of internal audits, which we refer to as our Quality Assurance measures. It is important in any human service organization, particularly one that is as spread out as we are, to be as transparent as possible. Directors and Program Managers need to be able to ensure that services are being delivered in the proper ways, at the proper times, and to the right people. by Tim Pray
eople will be getting better service because there will be smaller caseloads. — Jeff Sturm, DPHHS
2007 session mostly positive for AWARE, other providers The end of the 2007 session of the Montana Legislature and the brief special session that followed had some providers of human services breathing sighs of relief and others rejoicing. “While the 2007 Montana Legislature was one of the most difficult and contentious sessions ever experienced in the state, the end result for health and human services was very positive,” said Jani McCall, executive director of the Billingsbased Montana Children’s Initiative Provider Association and a veteran lobbyist. “The Legislature approved significant funding and services for at risk children and their families,” she said. For AWARE, the session also was mostly good news.
New positions “AWARE should see in the new biennium (beginning July 1) increased funding from a variety of avenues – community mental health and children’s mental health, community developmental disabilities funding, and notably in development disability case management will see not only an award of new positions but funding for salaries,” said lobbyist Charlie Briggs of CWB Consultation in Helena. McCall, meanwhile, noted that the human services budget for the Department of Health and Human Services boosted the two-year appropriation to $775 million, with nearly $160 million in new general fund dollars due primarily to changes in the state matching rate for
Medicaid, and caseload and services increases (most notably in Medicaid), as well as direct care worker wage and provider rate increases. Specifically, child protective services increased by $17.2 million general fund, with $7.9 million going to increases in foster care and subsidized adoption caseloads. Children’s mental health received $24.2 million additional funds over the biennium, including $7.3 million general fund for increases in children’s mental health Medicaid services in Children’s Mental Health Bureau. For the first time, McCall said, the Governor’s office and Legislature supported “flexible funding sustainability” for the Children’s System of Care – a multi-agency planning effort with strong family involvement. A special revenue account was approved for deposit of flexible funds from state agencies working with at risk youth. Use of up to $1 million of existing funds was approved for “creative services.” “These are community based services, such as respite care for kids in families that are not eligible for Medicaid,” McCall explained. “These services reduce out-of-home placement for kids.” Legislators also OK’d matching funds to lower the number of highrisk young people in out-of-home placements. A bill sponsored by Great Falls Democrat Rep. Eve Franklin set aside $500,000 in each of the next two years. “This was a huge gift to us,” McCall said.
Insurance coverage Also for the first time, property damage and liability insurance coverage will be provided for all foster parents in Montana, including therapeutic foster parents who care for
some of the most difficult seriously emotionally disturbed youth. Children’s provider rates increased 1.86 percent each year in child welfare and 2.5 percent in year one and 1.85 percent in year two in children’s mental health. Mary Dalton, the Health Resources Division Administrator told MCI members recently that the provider rate increases will be 3.3 percent starting Oct. 1, 2007, and 1.03 percent July 1, 2008. Along with all other health and human service direct care workers, people working with children received additional direct care wage increases of $.70. The Legislature required that all direct care workers be brought up to a minimum wage of $8.50 per hour.
Worker wages What does that mean for AWARE, which already has a minimum living wage of $9.07 an hour? “Note that the benchmark for direct care worker wages in community DD services (only) is allowed to be at $8.35 per hour minimum entry level wage, instead of the $8.50 that all other providers were expected to meet,” Briggs said. “This was because an analysis by the Legislative Fiscal Division staff determined the direct wage increase portion for DD was proportionately less than others and therefore might find it a stretch to ensure the $8.50 entry level wage by July 1,” he said. Also note that funding for the DD waiting list was kept at the minimal level ($3 million total over the biennium) approved by the joint human services sub-committee in the regular session. “That was because they agreed with DD providers that first there needed to be sufficient new dollars to strengthen community infrastructure before seeking to meaningfully address the waiting list,” Briggs said. Continued on page 10
Continued from page 9
The department had recommended to the governor’s budget a minimum $30 million increase over the new biennium and the final appropriation came in about $7 million less, “though there was a fairly healthy increase nonetheless,” he said. The non-DD provider rate increase was requested to be 2.5 percent each year. “However, with delaying the implementation of the new rates from July to October 2007 – then using the same amount of increase for FY 2009 – it means the overall increase has dropped to about a 1.8 percent provider rate increase,” Briggs said. “This will affect AWARE only in mental health services, I believe, as DD provider increases were covered in the rebasing fund increase and, of course, the direct care worker wage increase.” Overall, the health and human services budget grew by $400 million for the biennium to a total of $3.1 billion, a 13 percent increase. The total budget for the Department of Health & Human Services, including federal Medicaid funding is $8.8 billion. The Department of Corrections saw a 25 percent increase – $67 million – plus $28 million to cover cost overruns from the current biennium. McCall noted that the session began with more than $1 billion in surplus and ended following the special session with an anticipated ending fund balance for the ’09 biennium of $187 million. If there was a downside for children’s mental health, McCall said, it was that the governor and Legislature chose to address – only minimally – a change coming this fall from the Centers for Medicaid and Medicare Services (CMS) at the federal level regarding how certain children’s mental health services are being paid for. CMS is requiring states to “unbundle,” or separate, actual clinical services from support services and
he legislature approved significant funding and services for atrisk children and their families.—Jani McCall, Montana Children’s Initiative will pay only for approved clinical services. In Montana, the services affected are children’s therapeutic foster care, therapeutic family care and therapeutic group care. “These changes could result in a major restructuring and/or potential loss of these services,” McCall said. A provider/state agency work group has been meeting regarding these changes and creating a new model for funding. Here’s McCall’s list of bills affecting children’s services: HB 57 sponsored by Rep. Eve Franklin (D – Great Falls) provides liability and property damage insurance for all foster parents including therapeutic foster parents. Effective July 1, 2007. HB 98 sponsored by Franklin sets up a special revenue account for flexible funding to reduce out of home placements for youth. This bill also allows up to $500,000 per year of the biennium of existing Children’s Mental Health Bureau funding to be used for creative services. HB 437 sponsored by Rep. Dave Gallik (D – Helena) provides for a dispute resolution clause in social service agencies. Effective July 1, 2007. HB 514 sponsored by Rep. Mary Caferro (D – Helena) prohibits sexual contact between staff and residents in out of home social service agencies. Effective July 1, 2007. HB 769 sponsored by Rep. Bob Lake (R – Hamilton) requires registration of alternative adolescent
programs. Effective upon passage. HJR 26 sponsored by Rep. Tim Callahan (D – Great Falls) allows for the study of mental health issues in the criminal and juvenile justice systems under the direction of the Law and Justice Interim Committee. SJR 6 sponsored by Sen. Trudi Schmidt (D – Great Falls) allows for the study the juvenile justice system and it under the direction of the Law and Justice Interim Committee. SB 206 sponsored by Sen. John Cobb (R – Augusta) requires DPHHS to conduct a study to determine feasibility, impact and cost of providing employer-sponsored health insurance to certain Medicaid providers. It is targeted first to apply to personal-care attendants and directcare employees in Medicaid funded long-term care facilities. Effective April 26, 2007. SB 419 sponsored by Sen. Greg Lind (D – Missoula) allows children to remain covered by parent’s health insurance to age 26. Effective January 1, 2008. SB 45 sponsored by Sen. Dan Weinberg (D – Missoula) revises laws governing inpatient behavioral health facilities. Effective July 1, 2007. SB 81 sponsored by Sen. Trudi Schmidt (D – Great Falls) includes licensed psychologists as statutory providers. Effective July 1, 2007. SB 382 sponsored by Sen. Jessie Laslovich (D – Anaconda) allows district courts or courts of limited jurisdiction to establish voluntary mental health treatment courts. No funding was provided. Effective July 1, 2007. SB 478 sponsored by Sen. Dan Weinberg (D – Missoula) implements a suicide prevention program. Effective July 1, 2007. McCall also provided this summary of the budget approved in the special session.
Children’s mental health: $1,300,036 in provider rate increases at 1.86 percent each year of
the biennium for foster care, shelter homes and group home providers and other child welfare provider rates starting Oct. 1, 2007, (dollar amount is still being calculated) for 2.5 percent provider rate increases the first year of the biennium and 1.85 percent the second year of the biennium for children's mental health provider for treatment rates starting Oct. 1, 2007. $899,822 in Direct Care Wage increases for Child & Family Services Division bringing lowest paid wages to $8.50 per hour and an additional $0.31 per hour for all direct care workers in CFSD. $307,547 total funds for equalization of Campus Based Therapeutic Group Home rates. $600,000 contingency for the “unbundling” of Therapeutic Group Homes and Therapeutic Foster Care rates being required by Medicaid. $743,294 over the biennium for Children's System of Care sustainability. $308,000 match for the new federal Deficit Reduction Act grant for reducing out of home placements for youth in CMHB. This is the new pilot project with the Yellowstone County Kids Management Authority $500,000 (one time only) for Mental Health Case Management increase in CFSD. $800,000 over the biennium for Youth Suicide Prevention Program in HRD. $24.2 million additional funds over the biennium, including $7.3 million general fund for increases in children's mental health Medicaid services in CMHB. Base level expenditures were $54.7 million funds including $15.2 million general fund. $17.2 million general fund including $7.9 million for increased foster care and subsidized adoption caseload in CFSD. $375,000 general fund for a one-time-only contingency fund and $125,000 federal funds over the biennium for mental health case management in CFSD.
$149,000 general fund over the biennium for foster care liability and property damage insurance in CFSD. $3.6 million general fund OTO for replacement of federal fund reimbursement for Targeted Case Management in CFSD. $172,000 general fund to replace federal reimbursements eliminated by the Deficit Reduction Act for Kinship Care in CFSD. $1 million for the biennium of existing Children’s Mental Health Bureau (CMHB) budget (no new funds) for creative services to reduce out-of-home placements. Additional funding for Children’s Health Insurance Program (CHIP) was provided and discretion was given to the Department of Public Health and Human Services (DPHHS) to increase the eligibility level from its current 150 percent of the federal poverty level to up to 175 percent.
Adult mental health Adult mental health direct care worker increase: $716,675 per year of biennium Behavioral health inpatient
facilities: $3 million in Fiscal 2009 Mental health drop in centers: $371,647 per year of biennium Suicide prevention: $400,000 per year of biennium (adults and children) Services for mentally ill offenders: $371,647 per year of biennium Expand Mental Health Service Plan: $2,601,531 per year of biennium 2.45 percent Medicaid adult mental health provider rate increase for ’08 and 2.32 percent in ’09 and 1.39 percent non Medicaid for ’08 and 2.34 percent for ’09. Drugs for mentally ill offenders: $950,000 in year one 72 hour crisis care: $2 million per year Methamphetamine treatment: $2 million per year MHSP drugs: $6.3 million in year one Community liaison officers: $129,522 in year one; $145,000 in year two Service Area Authority grants: $115,000 per year
Wallace Sutter, work services manager, oversees auto detailing while Lucero supervises the employees. Lucero, who had experience in auto detailing from a former job, first suggested the notion of opening a shop for AWARE consumers in 2005. Since AWARE already had the warehouse, it was a natural fit. AWARE staff put together a business plan and then visited local car lots during the summer of 2005 announcing the opening of the shop. Since then the detailing crew has done hundreds of vehicles. They provide full service to their customers: an exterior wash, interior cleaning, including a carpet and upholstery shampoo, engine cleaning, and waxing and buffing. They use the same equipment and soaps and solvents that any commercial shop would use. They also take walk-in requests. “Word of mouth has brought in a few customers off the street,” Lucero said. The price is right. A full-service detail on a sedan is $78. For a pickup, van or SUV, the cost is $80 to $85. The shop also offers volume pricing. But volume isn’t the most important thing. “Right now, it’s not about the number of vehicles we can do,” Lucero said. “It’s about giving consumers opportunities for employment. The Auto Detailing Shop has been an excellent way for our consumers to learn work skills and be employed.” By Jim Tracy
Shrink wRap By Ira S. Lourie, M.D.
those problems. If the problems don’t get better, then they accepted the fact that they had failed to help the child. In the meeting, they then would decide what new approach was necessary.
Does AWARE Do Unconditional Care? In the last Shrink wRap column, I talked about the principles of wraparound services and the concept of unconditional care. I discussed that unconditional care meant never giving up on kids and their families, no matter what one has to do. This means not kicking kids out because they fail in our programs; rather, it means we adjust our services to better meet the needs of people we are serving.
What a startling concept! “We failed, and not the child.” This concept of unconditional care is what AWARE accepted as a value back in 1996 and 1997.
I once had the opportunity to visit a residential program which was Dr. Ira part of a state-wide system of care in North Carolina. This program was called the Willie M. Program and was the first program in the country to use the term wraparound. They had a whole range of community-based services, such as treatment foster care, group homes and home-based services, pretty much like AWARE. The also had two residential programs, where kids who needed that level of service could stay for a while before moving back into the community. The people in one of those programs taught me a very powerful lesson on unconditional care.
We have tried our hardest to make it part of the way we operate, but this year, members of the management staff decided that the organization was not being as unconditional as we once had been and that maybe Lourie we needed a jump start to get us back on the right track.
While I was visiting, I asked them what they did when a kid “goes off?” I expected that they would tell me their form of holding or how they talked kids down. Rather they said, “We have a meeting.”
In response, an Unconditional Care Commission was created. The members of this Commission include several members of the management staff, and we are working together to come up with a better understand of what values drive what we do in AWARE services and what it means to be more unconditional. Got any ideas? If you do, send me an e-mail, call me or fax me with your ideas, so that the commission can have as much input as possible. My e-mail is firstname.lastname@example.org; my phone is 301733-2633; and, my fax is 301-733-7388. When the Commission gets further with its work, we will report on it here in Shrink wRap.
“What do mean, ‘You have a meeting?!!!!’” I replied. They then told me that they would have a meeting in which they asked themselves the question, “How did we fail to meet that child’s need?” They accepted the fact that the children who were sent to them had problems, and that the job of the program was to help the kids do better with
For a review of Dr. Lourie’s book, “Everything is Normal Until Proven Otherwise,” please see page 14 in this issue of AWARE Ink. 12
Worth Reading Building the Bonds of Attachment By Daniel Hughes In novel form, Building the Bonds of Attachment is the second edition of a critically acclaimed book for social workers, therapists, and parents who strive to help poorly attached children. This composite case study chronicles the development of one child following years of abuse and neglect. The book has a double focus: specialized psychotherapy and parenting. It blends attachment theory and research, and trauma theory and general principles of both parenting and child and family therapy. It’s a practical guide for the adult—whether professional or parent— who wants to help such children.
Each issue of AWARE Ink will include a list of books recommended by staff covering a range of topics related to the work we do. This issue features titles suggested by Kathleen Green Nelson, an AWARE service administrator in Bozeman. Kathleen holds a master’s of science degree in health and human development from Montana State University in Bozeman. How to Talk So Kids Will Listen & Listen So Kids Will Talk By Adele Faber and Elaine Mazlish
How to Talk So Kids Will Listen provides a stepby-step approach to improving relationships between parents and their children. It features “reminder pages,” cartoon illustrations and exercises aimed at helping parents talk and problem-solve with their children. The book can be used alone or in parenting groups and is appropriate for kids of all ages. The Explosive Child: A New Approach for Understanding and Parenting Easily By Ross W. Greene Flexibility and tolerance are learned skills, as any parent knows if they’ve seen a testy 2-year-old grow into a pleasant, thoughtful, and considerate older child. Unfortunately, for reasons that are poorly understood, a few children don’t “get” this part of socialization. Years after toddler tantrums should have become an unpleasant memory, a few unlucky parents find themselves battling with sudden, inexplicable, disturbingly violent rages—along with crushing guilt about what they “did wrong.” Medical experts haven’t helped much: the flurry of acronyms and labels (Tourette’s, ADHD, ADD, etc.) seems to proffer new discoveries about the causes of such explosions, when in fact the only new development is alternative vocabulary to describe the effects. Ross Greene, a pediatric psychologist who also teaches at Harvard Medical School, makes a bold and humane attempt in this book to cut through the blather and speak directly to the (usually desperate) parents of explosive children.
Filial Therapy: Strengthening Parent-Child Relationships through Play By Rise VanFleet Best if used in conjunction with therapy, this book teaches parents how to do play therapy with their children. Filial therapy combines psycho-educational, empowerment and play therapy, actively involving parents in the child’s treatment. The guide describes techniques to use with 3- to 12-year-old children who are experiencing a wide range of clinical problems. Topics include how to actively engage parents in therapy, selecting toys, maximizing the effectiveness of parent education, handling common therapy problems, and applying filial therapy to a variety of social, emotional, and behavioral problems. An extended case example illustrates the different phases of therapy, resources for child and family therapists, psychologists, psychiatrists, social workers, pediatric and family physicians, mental health professionals, nurses, educators, guidance counselors, play therapists, and early childhood specialists and caregivers. Reviving Ophelia: Saving the Selves of Adolescent Girls By Mary Pipher American girls are increasingly falling prey to depression, eating disorders, addictions and thoughts of suicide. Mary Pipher, Ph.D., a psychologist with a private practice in Lincoln, Neb., attempts to explain why. She discusses the pressures teenage girls are
subjected in her ground-breaking book, Reviving Ophelia. Pipher contends that we live in a look-obsessed, media-saturated, “girl poisoning” culture. The culture encourages girls to stifle their creative spirit and natural impulses. The danger, Pipher says, is that instead of blaming the culture, girls blame themselves or their parents. Escalating levels of sexism and violence—from undervalued intelligence to sexual harassment in elementary school—are causing girls to stifle their creative spirit and natural impulses. Ultimately, Pipher says, their self-esteem is destroyed. Her book includes the voices of girls from the front lines of adolescence. Reviving Ophelia offers parents compassion, strength and strategies for reviving these Ophelias’ lost sense of self.
Everything is Normal Until Proven Otherwise By Karl W. Dennis and Ira S. Lourie
Raising Cain: Protecting the Emotional Life of Boys By Dan Kindlon and Michael Thompson When they began writing Raising Cain, Bostonarea child psychologists Dan Kindlon and Michael Thompson thought they’d offer a “how-to” book for parents. Drawing on their years of counseling boys and their families privately and at two Boston-area private boys’ schools, the co-authors use real-life case studies and research findings to plow through issues touching the lives of all boys not just troubled ones. The book starts with basics—early education, discipline, father-son and mother-son relationships— then moves into the new, rockier territory of adolescence: anger and violence, relationships with girls, drinking and drugs, depression and suicide. As their manuscript progressed, Kindlon and Thompson realized a simple “how-to” would not do. “In the end,” they write, “we found that the best advice we had to offer was simply to understand boys as they truly are rather than as they appear or as we wish them to be. “Our deepest wish is to pull aside the curtain boys so tenaciously draw around themselves and offer you a look inside their hearts and minds. If we succeed, we hope that you will see more clearly the ways in which our culture conspires to limit and undermine their emotional lives. We hope you will understand boys better, and above all, we hope you will enjoy them more.”
If it could be said that there was a book that represented AWARE’s core philosophies in relation to provider-client relations and care, Everything Is Normal Until Proven Otherwise is that book. Drawing on his own history in the field of child psychiatry—along with the stories of his colleague, Karl W. Dennis—Dr. Ira Lourie, AWARE’s Medical Director, gives succinct, real-world examples of the importance of wraparound services. Through his decades-long experience, Dr. Lourie has come to realize that the comfort of an organization that quickly transitions children out of a program because they display problems perceived to be too intense may be good for the organization’s Public Relations efforts, but certainly not good for the child. As he discusses in his column in this newsletter, Dr. Lourie invests in the idea that, when a child does not succeed in a program, or acts out more than expected, it is of utmost importance for those in charge of the child’s care to decide what THEY could have done differently. Everything is Normal Until Proven Otherwise is testament to the idea that a child’s services should be based on his/her strengths, which, by nature, are individualized, and the book reflects that clearly by establishing characters as carefully as a fictional text. Lourie and Dennis remind us throughout that—although a provider of services is not the parent of a child—the provider assumes many of the traditional roles of the parent. The most important of these is consistent and unconditional care, constantly reinforcing the notion that, despite momentary problems, the child will not be abandoned. The concepts discussed in the book are not easy. It is one thing to submit to the idea of wraparound services on paper but an entirely different matter to follow through in the daily routine of caring for a youngster. It is exciting, though, to read this book and know that you are a part of the application of the ideas contained in it.
Quality Assurance becomes job No. 1 Form and chart revisions reflect core values
AWARE is putting its own spin on an old Ford Motor To get up to speed on the requirements, Highland Co. slogan. studied Montana codes and administrative rules, pored “Quality Assurance is Job 1” for a team of AWARE, over AWARE’s policies, procedures, mission, vision Inc., staff led by Program Officer Pandi Highland, who and values, scrutinized contractual requirements and has been on a crash program to improve the way we familiarized herself with the standards of the Commission on Accreditation of Rehabilitation Facilities, or CARF. organize our charts and clinical material to assure that services are delivered at the highest standard and quality. She said the revisions to AWARE forms and charts The floor of Highland’s office in Butte has been will meet the needs of the state and federal bureaucracies, littered with various forms and charts since she started but more importantly, “reflect our unconditional care core with AWARE on April 10. values” — the importance of families and building upon She is spearheading an effort to realign strengths, for example. documentation requirements with organizational values They will also continue to meet CARF standards. – focusing on strengths and recognizing families as the AWARE is among the few licensed mental health centers most important resource and drivers of treatment. in Montana holding itself to a national and industry “Over the past several years AWARE has articulated standard by being fully nationally accredited. its unconditional care core values and wraparound Intake forms, for example, now include “family philosophy,” said Chief Operations Officer Jeff Folsom. language,” Highland said. “It simply has not been enough to “The forms are shorter. They’re more provide training alone. These values his is our efficient. And they’re personalized,” she said. need to be embedded in the day-to-day “There is a new emphasis on assessing family commitment efforts of our workers at every level of strengths and the natural supports and assets to the families we available to our families through Montana’s engagement. “This is our commitment to the thriving communities.” serve. families we serve. We are looking at all “We are also reinvigorating our effort to — Jeff Folsom aspects of our work to better support track outcomes to further help our families families and provide them the tools recognize their success and to help us necessary to make informed decisions organizationally recognize where and how we and care for their children. We believe that family is the can continue to improve as a provider,” Folsom said. “We base on which individual strengths are built.” are re-doubling our efforts around child and family team “This is a very high priority,” said Highland, a meetings to assure that families are in a leadership role licensed clinical social worker. “Attention to detail is and well prepared for making the important decisions for so important. We know our staff do their jobs well, but their families that are often required.” improving our charts and clinical material is one way for Revision of various forms and charts and how us to be certain that we are doing our jobs efficiently and AWARE documents those are just part of an overall effort effectively. to make organizational improvements, Folsom said. “We are not only focusing on meeting state “AWARE has also created new lead clinical positions requirements for documentation but also demonstrating to oversee the implementation and to provide oversight, AWARE’s commitment to exceed state standards and education, and assurances that we deliver services to these deliver services within the systems of care philosophy.” high standards,” he said. Some AWARE staff began using the new forms Increased efforts by state and federal officials to in practice following a one-day training for youth case identify documentation deficiencies and increase funding managers in Anaconda on July 11. recouped from Medicaid providers is mandated by the Highland plans to take the training on the road over Deficit Reduction Act. the next two months to AWARE offices across the state. “If our charts aren’t up to state standards at the time “We’re aiming for agency-wide implementation of a state or federal chart audit,” Highland said, “we are within 90 days,” she said, “but I should be done in 60 put in the position of making significant repayments to the days (by mid-September) if I get lucky.” state regardless of whether the service was delivered.”
Child Evaluation Center to receive accreditation A nationally known facility providing forensic interviews and medical evaluations for children up to 18 and adults affected by developmental disabilities will soon receive accreditation, the Montana Health Care Industry Partners for Health newsletter reports in its summer 2007 issue. The Child Evaluation Center in Butte will be the first center in Montana accredited by the National Children’s Alliance. The center does interviews and evaluations for victims of sexual abuse, physical abuse, and/or witnesses to violent crimes. The Child Evaluation Center, operated by the Butte Community Health Center (CHC), has seen approximately 400 children since beginning operation in 1998, Partners for Health reports.
Anthropologist questions ‘autism epidemic’ A Time magazine article titled “What Autism Epidemic?” has created a controversy in child development circles and caught the attention of AWARE staff. In the January 2007 issue, Time reporter Claudia Wallis asks—and answers—the question: What if there is no autism epidemic despite the apparent explosive increase over the last 20 years in the number of American children affected by the disorder? The story centers on a controversial new book, Unstrange Minds: Remapping the World of Autism, by George Washington University anthropologist Roy Richard Grinker. Grinker argues that the surge in autism numbers may be simply the result of changing definitions, changes in policy and greater awareness among parents, teachers and doctors. He knows first-hand what he writes about, having helped raise his own autistic daughter, Isabel.
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